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Scope: Isolated
Severity: Actual harm has occurred
Citation date: August 22, 2022
Corrected date: October 17, 2022
Citation Details **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interviews during the Recertification Survey and Abbreviated survey (NY 941 and NY 891) initiated on 8/15/2022 and completed on 8/22/2022, the facility did not ensure that each resident received adequate supervision and assistive devices to prevent accidents. This was identified for 2 (Resident #394 and Resident #35) of 7 residents reviewed for Accidents . Specifically, 1) Resident #394 required bilateral Ankle-Foot Orthoses (AFO) and Darco shoes (special orthopedic shoes) and two-person assistance for transfers from one surface to another. On 9/8/2021 Certified Nursing Assistant (CNA) #3 transferred Resident #394 without using the AFO and the Darco shoes and without the assistance of a qualified staff member to transfer the resident from the wheelchair to the bed. Subsequently, Resident #394 twisted their knee and fell resulting in left tibia, fibula and ankle fractures. 2) Resident #35 had a physician's orders [REDACTED]. Resident #35 fell out of bed when their bed was replaced with another bed that did not have bilateral padded upper siderails. Subsequently, Resident #35 fell out of bed and sustained a laceration under the left eye; a hematoma to the right forearm and the left forehead; and skin tears to the right elbow and to the right thigh. This resulted in actual harm to Resident #394 that is not Immediate Jeopardy. The findings are: 1) Resident #394 was admitted with [DIAGNOSES REDACTED]. The 6/28/2021 Admission Minimum Data Set (MDS) assessment documented a Brief Interview for Mental Status (BIMS) score of 14, indicating the resident was cognitively intact. The MDS documented that the resident required extensive assistance of two staff members for transfers. The Physician History and Physical dated 6/24/2021 documented that the resident was admitted from the hospital with multiple fractures involving the lumbar spine and bilateral pelvis. A Comprehensive Care Plan (CCP) dated 7/1/2021 titled the resident has an ADL self-care performance deficit related to impaired balance, limited mobility, and multiple fractures, documented interventions including but not limited to transferring the resident as per the CNA tasks. The CCP did not provide specific directions related to assistance and devices required to transfer Resident #394 from one surface to another. A rehabilitation note dated 8/26/2021, written by a Physical Therapy Assistant and co-signed by a Physical Therapist, documented Resident #394 was issued bilateral AFOs to prevent knee buckling A rehabilitation note dated 8/26/2021, written by a Physical Therapy Assistant and co-signed by a Physical Therapist, documented Resident #394 requires a Lumbar Sacral Orthotic and bilateral AFOs and Darco (shoes) donned (put on) for all Out of Bed (OOB) activities. The resident no longer utilizing a Mechanical Lift. A physician's orders [REDACTED]. The Kardex Report (CNA task instructions-directions provided to CNAs how to provide care to the resident) as of 9/7/2021 documented to transfer Resident #394 with extensive assistance of two staff members, [MEDICATION NAME]-Lumbar-Sacral Orthosis (TLSO), and bilateral AFOs with Darco shoes. A nursing progress note written by Registered Nurse (RN) #1, unit RN, dated 9/8/2021 at 9:15 PM documented the writer (RN #1) was requested by the Resident Care Assistant (RCA) #1 at 5:15 PM to assist CNA #3 in Resident 394's room. Upon arrival the resident was noted crouched on CNA #3's knees with CNA #3's hands under the resident's arms. RN #1 and CNA #3 attempted to bring the resident up but were unable to do so. RN #1 and CNA #3 then lowered Resident #394 to the floor on the resident's buttocks and straightened the resident's legs out. Resident #394 complained of left lower extremity pain when the legs were being straightened out. The resident stated their leg was twisted when crouched down. The physician was made aware, and x-rays were ordered. X-ray results showed acute [MEDICAL CONDITION] malleolus (ankle) and distal fibula and tibia. The resident was transferred to the hospital (9/8/2021). A physician's orders [REDACTED].#394 out of bed until Lower Extremity x-ray results are done. Radiology Report Results dated 9/8/2021 documented acute fractures of the left distal tibia and fibula and acute fracture of left medial malleolus and lateral malleolus. A physician's orders [REDACTED]. A nursing progress note dated 9/9/2021 documented Resident #394 returned from the hospital. [DIAGNOSES REDACTED]. Resident #394 returned with a soft cast and an ace wrap to the left lower extremity and was NWB to the left lower extremity and a knee immobilizer to the right lower extremity. An orthopedic consultation note dated 9/23/2021 documented Resident #394 sustained a left ankle fracture on 9/8/2021. The plan included to continue NWB status to the left ankle. A review of the Accident and Incident (A/I) report dated 9/8/2021 prepared by the Assistant Director of Nursing Services (ADNS)/Risk Manager documented after conducting interviews and performing re-enactments, it is unclear if CNA #3 used RCA #1 for the transfer. Despite all attempts CNA #3 and RCA #1 continued to have different accounts of the incident. Either way, the transfer was not done correctly. A written statement from CNA #3 in the 9/8/2021 A/I report documented CNA #3 asked the resident to allow them (CNA #3) to transfer the resident back to bed using a lift. Resident #394 used a walker and two people and did not want the lift; however, the resident wanted to go to bed because they (Resident #394) were tired. RCA #1 was in the room and CNA #3 asked RCA #1 for help transferring the resident. CNA #3 wrote that they (CNA #3) were not aware that the RCAs could not assist with transfers. As CNA #3 and RCA #1 stood the resident from their wheelchair, Resident #394 said their (Resident #394) knees started to buckle. The resident started to go down to the floor and RCA #1 then went to get the nurse. A written statement from RCA #1 in the 9/8/2021 A/I report documented RCA #1 and CNA #3 were in the resident's room. Resident #394 was insisting on being put back to bed. CNA #3 was going to use the Hoyer lift (mechanical lift) but the resident insisted they (Resident #394) can be transferred with a walker. CNA #3 pulled the resident's walker over and then asked RCA #1 to assist after the resident was already standing up. Resident #394 stated their legs were giving up. RCA #1 ran over and assisted CNA #3 to hold the resident up. Resident #394 started screaming that they (Resident #394) were going to fall. RCA #1 went to get the nurse. A written statement from Resident #394 in the 9/8/2021 A/I report documented CNA #3 and RCA #1 helped them (Resident #394) up from the wheelchair. When Resident #394 started to get up their knees started to buckle. Both the CNA and RCA were with me. The RCA could not help me, and the CNA could not help me alone. Resident #394 started to go down and their knees twisted and started to bend. Then they got the nurse and even though the nurse tried to help, (the nurse) could not help either. A written statement from the Assistant Director of Nursing Services (ADNS)/Risk Manager in the 9/8/2021 A/I report documented on 9/8/2021 at 5:15 PM Resident #394 asked CNA #3 to put the resident back to bed. In preparation for getting in bed, the resident had their (Resident #394) braces (AFOs) taken off and sneakers were put on at their (Resident #394) request. On re-enactment CNA #3 stated RCA #1 was in the room, so CNA #3 asked the RCA to assist with the transfer. RCA #1 stated they (RCA #1) were in the resident's room looking for a phone charger and did not assist with the transfer. RCA #1 explained that they (RCA #1) only went over to the resident to help break the fall. The Chief Nursing Officer was interviewed on 8/18/2022 at 11:00 AM and stated both CNA #3 and RCA #1 are no longer employed at the facility. There were multiple attempts made to contact both CNA #3 and RCA #1 without success. The RN Nursing Educator was interviewed on 8/18/2022 at 2:28 PM and stated CNAs are aware of what the RCAs can do and cannot do, and RCAs are aware of what they can do. The RN Nursing Educator stated CNAs are taught specifically what an RCA can do, which is in the CNA orientation manual. The RN Nursing Educator stated CNAs get copies of the CNA job description and the RCA job description and also verbal instructions of what the RCAs can do. The 2021 CNA Inservice Record documented that CNA #3 received inservice education on 8/9/2021 for Body Mechanics/Safe Patient Handling/Accident Prevention/Transfer Technique and on 8/10/2021 for following the plan of care and the CNA tasks in the Kardex. The facility's undated document, titled CNA Position Description, documented under the direction and supervision of a licensed nurse, provides high quality care to residents, as well as assists them with activities of daily living (ADLs), to ensure the residents attain and maintain their highest practicable well-being. CNA duties include assisting residents in and out of bed, chairs, and stretchers per the resident's plan of care. The facility's undated document, titled Daily Duties for Resident Care Assistants (RCA), documented No Transfers/No Toileting. The Rehabilitation Director was interviewed on 8/19/2022 at 9:55 AM and Resident #394's transfer should have been performed with the resident wearing the bilateral AFOs because the AFOs help with the transfer by stabilizing the resident's legs. The RN Nursing Educator was re-interviewed on 8/19/2022 at 11:27 AM and stated the AFOs should be removed after the resident is in bed because the AFOs are needed to stabilize the resident's feet. The Chief Nursing Officer was interviewed on 8/19/2022 at 11:57 AM and stated the transfer should be performed according to what the Kardex documents for the resident's transfer needs. The ADNS/Risk Manager was interviewed on 8/22/2022 at 2:15 PM and stated they (ADNS/Risk Manager) completed the investigation related to the incident with Resident #394 on 9/8/2021 and concluded that the AFOs were removed prior to the transfer talking to the staff involved, re-enacting the incident, and asking questions. CNA #3 told them (ADNS/Risk Manager) that the AFOs were removed prior to transferring Resident #394. The ADNS/Risk Manager stated that Resident #394 had bilateral artificial hip and knee joints and was morbidly obese. According to the 8/26/2021 rehabilitation department progress note, the AFOs were issued to prevent knee buckling. The Medical Director was interviewed on 8/22/2022 at 3:05 PM and stated removing the AFOs prior to the transfer if they were required for out of bed activities to prevent knee buckling would be a contributing factor to the fall. 2) Resident #35 has [DIAGNOSES REDACTED]. The quarterly Minimum Data Set (MDS) assessment dated [DATE] documented that the resident had severely impaired cognitive skills for daily decision making. The resident was totally dependent on two persons for bed mobility, transfers, and toilet use. The physician's orders [REDACTED]. The Authorization for Use of Side Rails form dated 12/7/2020 documented rationale for Resident #35's siderail use was bed boundaries due to impaired vision ([MEDICAL CONDITION]). The Certified Nursing Assistant Task assignment last revised 12/7/2020 documented under the standard task: Safety-Side rails-Padded Up in Bed for bed boundaries due to being legally blind. The Comprehensive Care Plan (CCP) entitled: The resident has an Activities of Daily Living (ADL) self-care performance deficit related to (r/t) impaired mobility and Terminal Dementia was initiated on 10/3/2020. The CCP was updated on 12/8/2020 to include bilateral padded side rails when in bed due to restlessness, confusion, and resident does not recognize bed boundaries. The CCP entitled: The resident has impaired visual function r/t [MEDICAL CONDITION] and being legally blind was initiated on 12/7/2020. The CCP was updated on 4/19/2021 to include bilateral padded upper side rails for safety due to being legally blind. The Physical Therapy (PT) Discharge Summary dated 12/24/2020 documented that the resident was dependent for bed mobility and transfers. The Incident Review Quality Assurance Form (Accident/Incident form) dated 6/8/2021 documented that at 3:15 AM, the resident was found lying on the floor, on the right side of the bed, on their right side. The resident was noted with a moderate amount of bleeding to a right forearm hematoma. There was a hematoma to the resident's left forehead with a laceration under the left eye measuring 2.0 centimeters (cm) by (x) 0.5 cm. There was a bump noted to the back of the right side of the resident's head. There was a right elbow skin tear measuring 2.0 cm x 2.0 cm and a right thigh skin tear measuring 1.5 cm x 0.5 cm. The Investigative Summary dated 6/15/2021 documented that on 6/3/2021 the nurse was notified that another resident needed a wide bed. Resident #35's wide bed that had the bilateral padded upper side rails was exchanged for a regular sized bed that did not have the bilateral padded upper side rails in place. The Certified Nursing Assistant (CNA), caring for Resident #35, did not put up the half side rails because the regular bed had none. The Director of Rehabilitation was interviewed on 8/17/2022 at 3:45 PM and stated that the resident's last PT assessment before the fall from bed on 6/8/2021 documented that they (Resident #35) were dependent on two staff members for bed mobility and transferred with a mechanical lift. The Maintenance Mechanic who exchanged the two beds on 6/3/2021 was interviewed on 8/19/2022 at 10:25 AM and stated that moving beds was common and happens weekly. The Maintenance Mechanic stated that a Nurse will tell them (Maintenance Mechanic) where to find the bed needed and switch it with another bed. The Maintenance Mechanic stated that the resident is taken out of the bed, both beds are cleaned by Housekeeping, and then they (Maintenance Mechanic) do the actual move. The Maintenance Mechanic stated that the Nurses tells them (Maintenance Mechanic) if a bed needs side rails because most beds do not have side rails. The Maintenance Mechanic stated that they (Maintenance Mechanic) do not add or take off the side rails unless they are told to by Nursing. The Maintenance Mechanic stated that they (Maintenance Mechanic) do not look if the beds have side rails or not when they (Maintenance Mechanic) move them. The Maintenance Mechanic stated that they (Maintenance Mechanic) tell the Nurse after the move is complete. The Director of Nursing Services (DNS) was interviewed on 8/19/2022 at 1:45 PM and stated that during the facility's investigation it was found that the resident's plan of care was not followed because the regular sized bed that the resident received did not have side rails. The DNS further stated that the side rails could have prevented the resident's fall. 415.12(h)(1) | Plan of Correction: ApprovedSeptember 8, 2022 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** I Resident # 394 no longer resides in the facility RCA #1 is no longer employed at the facility. CNA #3 was provided with a written disciplinary action and suspended for 5 days for failing to transfer resident #394 as per the residentÆs plan of care. This nursing assistant is no longer employed at the facility. Resident #35 had bilateral upper padded side rails in place on her bed on 6/8/21 upon return from hospital evaluation. Resident #35 currently resides at the facility and has all assistive safety devices in place as per MD orders and plan of care. Resident currently has bilateral upper padded side rails while in bed due to alternating air mattress for pressure ulcer prevention and bed boundaries due to visual impairment. A special CCP review was held on 9/2/22 to review her current plan for safety/risk for falls and side rails. The ADNS identified the nurse responsible for having resident #35Æs bed exchanged and failing to ensure the half side rails were in place as ordered by the MD. The licensed nurse received an educational counseling by the ADNS on 6/11/21 and 9/2/22. The ADNS developed a list of all nursing assistants and licensed nurses caring for resident #35 from 6/3/21-6/8/21 who failed to identify and report the resident did not have padded side rails in place as per MD order. All identified staff that had not received a prior counseling, will receive counseling from the ADNS/designee by 9/9/22 The current MD order, dated 9/7/22, for resident #35 documents that the resident is to have bilateral upper padded side rails while in bed due to alternating air mattress for pressure ulcer prevention and bed boundaries due to visual impairment. The authorization form for the use of side rails for resident #35 was updated and signed by the care plan team on 9/7/22 to include a directive that bilateral upper padded side rails are used for alternating air mattress for pressure ulcer prevention and bed boundaries due to visual impairment. The CCP for Activities of Daily living self-care performance deficit was revised on 9/7/22 to include bilateral upper padded side rails when in bed due to alternating air mattress for pressure ulcer prevention and bed boundaries due to visual impairment. The CCP for visual function was revised on 9/7/22 to include bilateral upper padded side rails when in bed due to alternating air mattress for pressure ulcer prevention and bed boundaries due to visual impairment. The CNA task list for resident #35 identifies bilateral upper padded side rails when in bed due to safety. II A. The ADNS will review all accident/incident reports that have occurred since 6/8/21 to identify if there were any other incidents that occurred due to the lack of side rails when ordered or inappropriate transfer. Any quality issue identified will be referred to the CNO and Administrator for review and corrective action. B. The Director of Rehab identified all residents in the facility with physician orders [REDACTED]. This list was then used by the Director of Rehab to identify any resident using assistive devices to prevent accidents. All residents using assistive devices to prevent accidents will be reviewed by the Director of Rehabilitation/licensed therapist to do quality assurance chart reviews to ensure that physician orders [REDACTED]. Identified quality issues will have immediate correction. C. The CNO developed a list of all residents on the short-term rehab units that have directives to be transferred with a two person assist. The list will be utilized by the CNO/Designee to ensure the plan of care and nursing assistant task list are appropriately documented with this directive. Any quality issue identified will have immediate corrective action. The CNO/Designee will complete random audits for the residents on the short-term units identified as requiring a two-person assist for transfers to ensure transfers are being done as per plan of care. Any quality issue identified will have immediate corrective action taken and referred to Administrator for review. D. The CNO will develop a list of all residents in the facility identified as having physician orders [REDACTED]. Based up this list, medical record reviews will be done by Nursing Care Coordinator/Nurse Manager/designee to ensure the side rail order identifies clinical rational for use, CCP is in place, and CNA task is accurate. Additionally, rounds will be made by NCC/NM/Designee to ensure side rails are present and used according to MD order on all identified residents. Any quality issue identified will have immediate corrective action taken. III A. The Director of Rehab and CNO reviewed the facility policy on Assistive/Adaptive devices and equipment. The policy was revised to include a directive that residents with assistive devices recommended by the licensed therapist(s) for safety and prevention of accidents will now include specific directions for wearing. The licensed therapist will document this on the rehab communication form and appropriate MD order will be obtained. The licensed nurse will then transfer the rehab directives and MD orders onto the CNA task list and plan of care. All licensed therapists will be in-serviced on the revised policy by the Director of Rehab and all nursing staff will be in-serviced on the revised policy by the Educational Coordinator/Designee The lesson plan will focus on the following: - Overview of F689 and providing necessary assistive devices and supervision to prevent accidents - Purpose of assistive devices in preventing accidents - Documenting assistive devices on the rehab communication form - Obtaining physician orders [REDACTED]. - Documenting wearing specificity of assistive devices for implementation on plan of care and CNA task list - Communication when resident refuses assistive devices as recommended A copy of the lesson plan and attendance will be maintained for validation. B. The CNO reviewed the facility policy on side rails. The policy was revised to include a directive that the nursing assistants assigned to care for a resident with orders for side rails will document each shift if the side rails were in place and used on the CNA task list. All nursing staff will be in-serviced by the Educational Coordinator/Designee on the revised side rail policy. The lesson plan will focus on the following: - Purpose of side rails - MD orders for side rails - Developing a plan of care for residents using side rails - Communication with nursing assistants when side rails are in use - Documenting each shift that side rails are being utilized - Staff responsibility when bed change is done to ensure plan of care is followed A copy of the lesson plan and attendance will be maintained for validation. C. The CNO reviewed the facility job description for resident care assistants. The job description was clarified to state the RCA is not permitted to provide any hands-on care. All nursing staff and RCAs will be in-serviced on the job description of resident care assistant by the Educational Coordinator/Designee. Additionally, all resident care assistants will sign the job description as validation. The lesson plan will focus on the following: - The role of RCAÆs - Tasks of RCAÆs - Job responsibilities of RCAs - Supervision of RCAÆs - Communication to licensed nurses A copy of the lesson plan and attendance will be maintained for validation. D. The CNO reviewed the facility policy on ADL care and the policy was revised to include directive that the CNA must review the CNA task list and Kardex to ensure adherence to the residentÆs plan of care. The policy was found to be compliant. All nursing staff will be in-serviced on the policy by the Education Coordinator/Designee. The lesson plan will focus on the following: - Developing and implementing a plan of care for residents for safety - Safety concepts and staff responsibility - Preventative measures and implementation of same - Overview of the CNA plan of care - Responsibility of nursing assistant to follow all components of plan of care - Communicating with licensed nurses any issues related to plan: refusal, noncompliance, complaints, safety concerns, etc. - Documenting that plan of care is followed - Strategies for managing situations when residents request/insist on care outside of the approved plan of care A copy of the lesson plan and attendance will be maintained for validation. E. The Director of Engineering and CNO will review the policy for bed exchange. The policy will be revised to include a directive to ensure that all adaptive equipment are in place at the time of the bed exchange. Inservice will be done on the revised on policy to all licensed nurses and engineering staff with emphasis on communication. A copy of the lesson plan and attendance will be maintained for validation. IV The Chief Quality Officer will develop an audit tool to monitor compliance with facility policy on documenting orders for assistive devices used for safety. Audits will be done to ensure all safety assistive devices have specific directives for wearing/use and are documented on CNA task list and CCP accordingly. Audits will be done by CQO/designee on 20 random residents using assistive devices for safety monthly x 3, quarterly x 3, then every 6 months. Any audit with quality issues identified will be referred to the CNO and Administrator for review and corrective action. All audit findings and any identified trends will be presented and discussed at the QAPI committee meetings for evaluation and follow up to ensure ongoing compliance thereafter. The CQO will develop an audit tool to monitor compliance with facility policy on ensuring side rails are in place as per MD order and are documented accurately on CNA tasks list and care plan. Audits will be done by CQO/designee on 20 random residents with orders for side rails monthly x 3, quarterly x 3, then every 6 months. Any audit with quality issues identified will be referred to the CNO and Administrator for review and corrective action. All audit findings and any identified trends will be presented and discussed at the QAPI committee meetings for evaluation and follow up to ensure ongoing compliance thereafter. The CQO will develop an audit tool to monitor compliance with facility policy on performing transfers as per CNA task list. Audits will be done by NCC/Designee on 20 random residents monthly x 3, quarterly x 3, then every 6 months. Any audit with quality issues identified will be referred to the CNO and Administrator for review and corrective action. All audit findings and any identified trends will be presented and discussed at the QAPI committee meetings for evaluation and follow up to ensure ongoing compliance thereafter The CQO will develop an audit tool to ensure staff awareness and compliance with the job description of Resident Care Assistant at the facility. Audits will be done by NCC/Designee by completing 20 random observation and interviews of staff including resident care assistants monthly x 3, quarterly x 3, then every 6 months. Any audit with quality issues identified will be referred to the CNO and Administrator for review and corrective action. All audit findings and any identified trends will be presented and discussed at the QAPI committee meetings for evaluation and follow up to ensure ongoing compliance thereafter. V. The CNO will be responsible for the correction of this deficiency by (MONTH) 17, 2022. |
Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: October 21, 2022
Corrected date: November 14, 2022
Citation Details **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and staff interviews during the Post Survey Revisit (PSR) conducted on 10/21/2022, the facility did not maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for one (Resident #1) of three residents reviewed for [MEDICAL CONDITION] care. Specifically, during observation of [MEDICAL CONDITION] care for Resident #1, who was on Contact and Droplet precautions due to Carbapenem-resistant [MEDICATION NAME] (CRE) in sputum and Extended Spectrum Beta-Lactamase (ESBL) infection in the urine, Respiratory Therapist (RT) # 1 did not utilize appropriate Personal Protective Equipment (PPE); did not follow infection control protocols while changing the [MEDICAL CONDITION] inner cannula; and did not wash their (RT #1) hands during the procedure. The finding is: The [MEDICAL CONDITION] Care and Documentation Policy dated 8/96 and last revised on 9/2022 documented procedures that included but were not limited to: wash hands, don (put on) gloves and any other PPE that may be appropriate, mask and goggles if risk of splashing. Remove disposable inner cannula and discard. Insert sterile disposable inner cannula make sure it snaps into place. The Handwashing/Hand Hygiene Technique Policy dated (MONTH) 2013 documented handwashing/hand hygiene is generally considered the most important single procedure for preventing healthcare-associated infections. The indications for antiseptic Handwashing included but were not limited to when providing resident care which involved bloody or body fluids, bodily excretion, and secretions. The Transmission Based Precaution Policy dated 7/15/2022 documented for residents on Contact Precautions the healthcare personnel caring for residents on Contact Precautions wear a gown and gloves for all interactions that may involve contact with the resident or potentially contaminated areas in the resident's environment. For residents on Droplet Precautions if there is a risk of exposure of mucous membranes or substantial spraying of respiratory secretions is anticipated, gloves and gown as well as goggles (or face shield) should be worn. The Personal Protective Equipment Policy dated 8/2021 documented to perform hand hygiene before donning gloves and after glove removal. The policy further documented that glove are not substitute for hand hygiene. The policy included gowns are to be worn to protect arms, exposed body areas and clothing from contamination with blood, body fluids, and other potentially infectious material. Indication/consideration for PPE use of gloves included but were not limited to: perform hand hygiene before donning gloves and after removal; gloves are not a substitute for hand hygiene; and change gloves and preform hand hygiene between clean and dirty tasks. Resident #1 was readmitted with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) assessment dated [DATE] documented Resident #1 had a Brief Interview for Mental Status (BIMS) score of 12 which indicated the resident had moderately impaired cognition. The MDS documented that the resident was ventilator dependent, required oxygen therapy, suctioning and [MEDICAL CONDITION] care. The physician's orders [REDACTED]. Change disposable [MEDICAL CONDITION] inner cannula every shift and as needed for hygiene. The Comprehensive Care Plan (CCP) for Multi Drug Resistant Organisms (MDRO) colonization, Pseudomonas aeruginosa, (Carbapenem Resistant) CRE in the sputum, and ESBL in the urine dated 8/31/2021 and last revised on 7/29/2022 documented Resident #1 was on standard and contact precautions effective 8/31/2021. Resident #1's care equipment be appropriately cleaned, disinfected, or sterilized according to facility protocol. The CCP for [MEDICAL CONDITION] for Impaired breathing mechanics, [MEDICAL CONDITION], vent dependence dated 5/06/2022 documented to provide [MEDICAL CONDITION] care daily and as needed. Resident #1, who was ventilator dependent, was observed for [MEDICAL CONDITION] care on 10/21/2022 at 10:40 AM. There was signage outside the resident's room with instructions Stop see the nurse for appropriate PPE use. RT #1 was wearing a face mask and eye protection; however, was not wearing a gown. RT #1 was observed donning a pair of disposable gloves without washing their hands before donning the gloves. RT #1 pulled Resident #1's privacy curtain around the resident's bed to provide privacy. RT #1 removed water cups, napkins, and pieces of gauze from the over-the-bed table then proceeded to clean Resident's #1 chest area. RT #1 set up the sterile field on the over-the-bed table to replace the resident's [MEDICAL CONDITION] inner cannula wearing the same gloves. RT #1 then opened a sterile glove packet while wearing the same disposable gloves. While wearing the same disposable gloves RT #1 was observed inserting their right-hand pointer, middle and ring fingers into the sterile glove as a second layer. RT #1 did not remove their soiled gloves and did not wash their hands before they opened and utilized the sterile glove. RT #1 was observed removing the [MEDICAL CONDITION] inner cannula with the right hand three fingers and then replaced the sterile inner cannula with their right hand while stabilizing the surrounding area with the left hand. RT #1 was interviewed on 10/21/2022 at 10:50 AM and stated that they do not remove their soiled gloves before they apply sterile gloves for any procedure. RT #1 stated they will not remove their used gloves and wash their hands before they open a sterile glove packet to apply the sterile gloves, since this was their routine practice. RT #1 stated there was no reason to remove the soiled gloves and wash their hands and that touching surfaces will not make the gloves soiled. RT #1 stated they did not use a disposable gown because Resident #1 did not have any infection control concerns. RT #1 stated they did not notice the stop see the nurse for appropriate PPE use sign that was posted outside the resident's room. RT #1 stated they were educated on the importance of washing their hands and using the correct technique to apply the sterile gloves; however, could not recall when they received the training. RT#1 stated that if we do not use the appropriate glove technique, the resident can get an infection because of germs on the gloves. RT #2 was interviewed on 10/21/2022 at 11:10 AM and stated that they overheard RT #1's sterile glove usage technique while they (RT#2) were outside Resident #1's room. RT #2 stated RT #1 was supposed to remove their soiled gloves and wash their hands before they applied the sterile gloves to change Resident #1's inner cannula. The Director of Respiratory Therapy was interviewed on 10/21/2022 on 2:00 PM and stated that RT #1 should have taken their soiled gloves off and washed their hands before applying the sterile gloves to complete the inner cannula change task. The Director of Respiratory Therapy stated that RT #1 put Resident #1 at risk of contracting bacteria, since RT #1 had not used proper technique for changing the inner cannula. The Infection Control Nurse, who is also the Director of Nursing Services (DNS), was interviewed on 10/21/2022 at 2:30 PM and stated that they educated RT #1 upon hire and periodically regarding hand washing and proper use of gloves. The DNS stated RT #1 failed to remove their soiled gloves prior to wearing sterile gloves. The DNS stated Resident#1 had an infection in the sputum and RT #1 put the resident at risk for further infection. RT#1's sterile glove technique was not acceptable. The DNS further stated that RT#1 should have worn a disposable gown while providing care to Resident #1 since the resident was on contact and droplet precautions. 415.19 (a)(1-3); 415.19(b)(4) | Plan of Correction: ApprovedNovember 9, 2022 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** I. Immediate Corrective Actions 1.The Respiratory Therapist involved in the care of this Resident who breeched Infection Control Practice was disciplined by the Director of Respiratory Therapy regarding the breech of Infection Control and failure to follow Policies as educated. 2.It was noted that this Employee had been recently educated and observed for competency on 10/17/22 and despite same violated Facility Policies, therefore the involved RT was terminated from the Facility on 10/21/2022 3.The Director of Respiratory Therapy will meet with all Respiratory Therapists on all shifts to review the deficient practice as recently cited with the staff; as well as to do on site education regarding infection control policy including: hand washing, glove use, Transmission-Based Precautions [MEDICAL CONDITION] to ensure compliance. A copy of this onsite education and attendance will be filed for reference and validation. 4. Resident # 1 was seen and evaluated by the MD Pulmonologist on 10/25/22 and no new acute infection was identified. A progress note was documented in the EMR to validate this assessment. 5. Currently, Resident # 1remains on Transmission-Based precautions with all Infection Control measures implemented during care by all staff per policy and infection control requirements. II. Identification of Other Residents 1. The Director of Respiratory Therapy compiled a list of all residents on the Vent Unit who are on Transmission-Based Precautions as well as have [MEDICAL CONDITION] Care. 2. This list will be used by the RT Director and IP Nurse/Designee to make immediate full rounds on all shifts targeting the vent unit to ensure all infection control policies are being followed as per facility policy. An observational rounds tool will be developed to validate the full house rounds. Any quality issues identified /and or corrective actions implemented will be documented for validation. 3. Any staff member identified with a breech of Infection Control during these observation rounds will have immediate onsite education to ensure compliance. 4. Copies of the observational rounds tool and any onsite education will be filed in our P(NAME) book for validation and follow up for ongoing compliance. 5. The list will be used by the Director of Respiratory Therapy to provide direct observations of Infection Control Competencies on the following: ò Awareness by RTs regarding Residents who are on Transmission-Based Precautions ò Appropriate signage and availability of PPE ò Criteria for Residents on Transmission-Based Precautions are being followed ò Wearing appropriate PPE including Donning and Doffing gowns, eye shields, masks (N95 in addition if appropriate) and gloves ò Appropriate Hand Hygiene and glove use 6. Any RT staff identified with quality issues regarding Infection Control procedures will be re-educated by the RT and additional competency will be done to ensure sustainable compliance. 7. A copy of the competencies will be filed in our plan of correction book for reference and validation. 8. The DNS/Infection Preventionist Nurse (IP Nurse)/Designee identified and compiled a list all Residents on Transmission-Based Precautions. 9. This list was used by the DNS/Designee to make full house rounds on all shifts to ensure that staff were following all Infection Control Policies for Infection Control compliance including the following: ò Awareness by staff regarding ResidentÆs who are on Transmission-Based Precautions ò Appropriate signage and availability of PPE ò Criteria for plan of care for Residents on Transmission-Based Precautions are being followed ò Wearing appropriate PPE including Donning and Doffing gowns, eye shields, masks (N95 in addition if appropriate) and gloves ò Appropriate Hand Hygiene and glove use 10. Any staff member identified during observational rounds with quality issues regarding Infection Control procedures will be re-educated by the nurse auditor and additional ongoing audits will be done to ensure sustainable compliance . 11. A copy of the observational rounds will be filed in our plan of correction book for reference and validation. III. Systemic Changes 1. The Facility has contracted with a consultant to assist and develop a Directed Plan of Correction as per New York State DOH Directives. 2. The facility conducted a QA meeting on 11/1/2022 to discuss recent findings and to identify the root cause that resulted in the facility failure. Based upon identifying the root cause analysis, the facility developed systemic changes to implement corrective actions. 3. A copy of the root cause analysis will be filed for reference and validation. The analysis revealed despite education and recent competency the RT failed to follow the facility policy on infection control. 4. The Director of Respiratory Therapy in conjunction with the IP nurse reviewed the policies on Transmission-Based Precautions and [MEDICAL CONDITION] Care with a concentration on Infection Control compliance, and found same compliant. 5. All respiratory therapists will be re-educated on the Policy for Transmission-Based Precautions and [MEDICAL CONDITION] Care by the Director of RT and/or Staff Educator/Designee to ensure understanding of all components of infection Control. 6. The Lesson Plan will concentrate on the following: ò Following the plan of care for Infection Control including interventions for preventing transmission of infection ò Overview of directives and protocols for residents on Transmission- Based precautions ò Appropriate Hand Hygiene and glove use, including when to wash hands per policy and when to change gloves ò Donning and Doffing PPE prior to entering/exiting the room ò Appropriate use of Face Shield/Goggles and Masks (in addition to N95, if appropriate) ò Overview [MEDICAL CONDITION] procedures with a focus on Infection Control Directives 7. A copy of the education and attendance will be filed for reference and validation 8. As per ôIdentification of Other Residentsö; the Director of Respiratory Therapy/Designee will perform Competencies on all staff RTs to ensure compliant Infection Control practice in Transmission- Based precautions as educated as well as [MEDICAL CONDITION] . ò Any RT staff identified with quality issues regarding Infection Control procedures will be re-educated by the RT Director/Designee and additional competency will be done to ensure sustainable compliance and comprehension of policies as educated. ò A copy of the competencies will be filed in our plan of Correction Book for reference and validation. ò The DNS/IP Nurse has reviewed the Policy on Transmission-Based Precautions; the policies have been found compliant with Infection Control requirements. ò All Nursing and Care staff will be re-educated on the Policy by the Staff Educator/Designee to ensure compliance in Infection Control Policies. 9. The Lesson Plan will concentrate on the following: ò Following the plan of care for Infection Control including interventions for preventing transmission of infection ò Overview of directives and protocols for residents on Transmission- Based precautions ò Appropriate Hand Hygiene and glove use, including when to wash hands per policy and when to change gloves ò Donning and Doffing PPE prior to entering/exiting the room ò Appropriate use of Face Shield/Goggles and Masks (in addition to N95, if appropriate) 10. A copy of the Lesson Plan and attendance will be filed in the P(NAME) Book for reference and validation of this education. IV QA Monitoring 1. The Facility held a Special review QA meeting on 11/1/22 to discuss the recent findings from the Facility re- survey. The meeting was facilitated by consultant. The meeting focused on causative factors that contributed to the deficiency as well as triggers that may indicate deficient practice based on DOH findings and Facility ongoing newly developed Infection Control audits and competencies 2. The QA Committee also discussed the root cause of this deficient practice as well as QAPI improvement plans for sustainable compliance in Infection Control 3. A copy of the Agenda and Attendance will be filed for reference and validation 4. The Chief Quality Officer will develop audit tools to track compliance with Infection Control protocols and residents on Transmission-Based precautions. 5. Audits and Direct Care Observations will be done daily, and Q shift over the next month then 20 random audits monthly x 3; then 20 random audits quarterly. The IP Nurse/RT Director/designee will focus on those residents on the vent unit, as well as other residents on Transmission-Based Precautions to ensure ongoing compliance with our policies. 6. Audits will include direct observations on following the plan of care including hand washing compliance, PPE appropriate use 7. Any negative findings will have immediate corrective actions implemented by the Director of RT/Designee to ensure compliance with all Infection Control protocols and to prevent transmission of infections. Any quality issues identified will be referred to the Administrator and Chief Quality Officer for follow up and review. All audit findings and any identified trends will be presented and discussed at the QAPI committee meetings for evaluation and follow up to ensure ongoing compliance thereafter. 8. QAPI Audit findings and any Infection Control issues will be discussed at the Morning Meetings for follow up as needed to ensure ongoing sustainable compliance by the team, as well as continuing audits as needed. Staff will be given direct assignments at the Morning Meeting for Infection Control monitoring as needed for ongoing compliance for any identified problems 9. In addition, all Infection Control audits will be presented at a weekly special review QA Meetings for follow up discussion , tracking of compliance, with our plan of corrections to ensure ongoing compliance. 10. All audit tools and QAPI Plans will have ongoing review by the DNS/IP nurse / Chief Quality Officer and Director of RT and continued as needed to identify any potential triggers or quality issues for follow up and compliance Responsible Person : Chief Quality Officer |
Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: August 22, 2022
Corrected date: October 17, 2022
Citation Details **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interviews during the Recertification Survey and Abbreviated Survey (Complaint #NY 891) initiated on 8/15/2022 and completed on 8/22/2022, the facility did not report an alleged violation related to an injury that resulted from not following the resident's plan of care to the New York State Department of Health (NYSDOH) within the required 24 hours. This was identified for one (Resident #35) of six residents reviewed for Accidents. Specifically, Resident #35 fell from their bed on 6/8/2021 which resulted in an injury, however the facility did not report the injury to the NYSDOH until 6/15/2021. The finding is: The facility's policy and procedure entitled Free From Abuse and Neglect dated 9/2017 documented: One element is needed for an incident of neglect to be reported to DOH: a) Failure to follow care plan with injury, (even just once, remember pain is an injury); or b) Repeated failure to follow care pan, with or without injury; or c) Failure to provide timely, consistent, safe, adequate and appropriate services. Resident #35 has [DIAGNOSES REDACTED]. The quarterly Minimum Data Set (MDS) assessment dated [DATE] documented that the resident had severely impaired cognitive skills for daily decision making. The resident was totally dependent on two persons for bed mobility, transfers. and toilet use and totally dependent on one person for locomotion on the unit, dressing, eating, personal hygiene, and bathing. The Authorization For Use of Side Rails from dated 12/7/2020 documented that the resident's son agreed for the use of side rails for Resident #35 for bed boundaries due to impaired vision ([MEDICAL CONDITION]). The physician's orders [REDACTED]. The Comprehensive Care Plan (CCP) entitled: The resident has an ADL (Activities of Daily Living) self-care performance deficit r/t (related to) impaired mobility and Terminal Dementia was initiated on 10/3/2020. An intervention initiated on this CCP on 12/8/2020 documented bilateral padded side rails when in bed due to restlessness, confusion, and resident does not recognize bed boundaries. The CCP entitled: The resident has impaired visual function r/t [MEDICAL CONDITION] and being legally blind was initiated on 12/7/2020. An intervention initiated on this CCP on 4/19/2021 documented bilateral padded upper side rails for safety due to being legally blind. The Incident Review Quality Assurance Form dated 6/8/2021 documented that at 3:15 AM, the resident was found lying on the floor, on the right side of the bed, on their right side. The resident was noted with a moderate amount of bleeding to a right forearm hematoma. There was a hematoma to the resident's left forehead with a laceration under the left eye measuring 2.0 cm (centimeters) x (by) 0.5 cm. There was a bump noted to the back of the right side of the resident's head. There was a right elbow skin tear measuring 2.0 cm x 2.0 cm and a right thigh skin tear measuring 1.5 cm x 0.5 cm. The Investigative Summary dated 6/15/2021 documented that on 6/3/2021 the Nurse was notified that a peer needed a wide bed. Resident #35's wide bed was exchanged for a regular sized bed so the peer could be in an appropriate bed, however Resident #35's wide bed had half side rails and the regular bed it was exchanged for, did not. The Certified Nursing Assistant (CNA) (caring for Resident #35) did not put up the half side rails because the regular bed had none. The Director of Nursing Services (DNS) was interviewed on 8/19/2022 at 1:45 PM and stated that during the facility's investigation it was found that the resident's plan of care was not followed because the regular sized bed that the resident received did not have side rails. The DNS stated that if the plan of care is not followed, the incident should be called into the NYSDOH within 24 hours. State Code? | Plan of Correction: ApprovedSeptember 8, 2022 I The CNO identified the Nursing Care Coordinator that failed to identify and report an alleged abuse violation related to an injury that resulted from not following the residentÆs plan of care for resident #35 to the ADNS. This NCC was provided with an educational counseling on 9/3/22 by the Chief Nursing Officer. Resident #35 had bilateral upper padded side rails in place on her bed on 6/8/21 upon return from hospital evaluation. The ADNS identified the nurse responsible for having resident #35Æs bed exchanged and failing to ensure that bilateral upper padded side rails were in place as ordered by the MD. The licensed nurse received an educational counseling by the ADNS on 6/11/21 and 9/2/22. The ADNS developed a list of all nursing assistants and licensed nurses caring for resident #35 from 6/3/21-6/8/21 who failed to identify and report the resident did not have bilateral upper padded side rails in place as per MD order. All identified staff that had not received a prior counseling, will receive counseling from the ADNS/designee by 9/9/22 Resident #35 currently resides at the facility and has all assistive safety devices in place as per MD orders and plan of care. Resident currently has bilateral upper padded side rails while in bed due to alternating air mattress for pressure ulcer prevention and bed boundaries due to visual impairment. A special CCP review was held on 9/2/22 to review her current plan for safety/risk for falls and side rails. The current MD order dated 9/7/22, for resident #35 documents that the resident is to have bilateral upper padded side rails while in bed due to alternating air mattress for pressure ulcer prevention and bed boundaries due to visual impairment. The authorization form for the use of side rails for resident #35 was updated and signed by the care plan team on 9/7/22 to include directive that bilateral upper padded side rails are used for alternating air mattress for pressure ulcer prevention and bed boundaries due to visual impairment. The CCP for Activities of Daily living self-care performance deficit care plan for resident #35 was revised on 9/7/22 to include bilateral upper padded side rails when in bed due to alternating air mattress for pressure ulcer prevention and bed boundaries due to visual impairment. The CCP for visual function for resident #35 was revised on 9/7/22 to include bilateral upper padded side rails when in bed due to alternating air mattress for pressure ulcer prevention and bed boundaries due to visual impairment. The CNA task list for resident #35 identifies bilateral upper padded side rails when in bed due to safety. II The ADNS will develop a list of all alleged violations related to an injury that resulted from not following the residents plan of care in the last 3 months. Based upon this list the ADNS will ensure that all alleged violations were reported to the NYSDOH as per requirement. Any quality issue identified will be referred to the CNO and Administrator for review and corrective actions. The DNS will develop a list of all grievances in the last 3 months. Based upon this list the DNS will ensure that all alleged violations involving abuse, neglect, exploitation, or mistreatment were reported to the NYSDOH as per requirement. Any quality issue identified will be referred to the CNO and Administrator for review and corrective actions. III The CNO and the Administrator reviewed the facility policy on Abuse and Neglect. The policy was found to be compliant. All NCC/Nurse Managers, and nursing leadership will be re-inserviced on the policy by the CNO/designee. The in-service will focus on the reporting of alleged violations in response to allegations of abuse, neglect, exploitation, or mistreatment. With emphasis on the requirements to report an actual and or alleged violation related to an injury that resulted from not following the residentÆs plan of care to the ADNS/Designee immediately and to proper authorities within prescribed timeframes. A copy of the lesson plan and attendance will be maintained for validation. IV The Chief Quality Officer developed an audit tool to monitor compliance with timeliness of reporting of all alleged violations involving abuse, neglect, exploitation, or mistreatment and reporting to NYSDOH as per policy/regulation. Audits will be done by CQO/designee on all accident reports and grievances monthly x 3, quarterly x 3, then every 6 months. Any audit with quality issues identified will be referred to the CNO and Administrator for review and corrective action. All audit findings and any identified trends will be presented and discussed at the QAPI committee meetings for evaluation and follow up to ensure ongoing compliance thereafter V The CNO will be responsible for the correction of this deficiency by (MONTH) 17, 2022. |
Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: August 22, 2022
Corrected date: October 17, 2022
Citation Details **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interviews during the Recertification survey and Abbreviated Survey (NY 250) initiated on 8/15/2022 and completed on 8/22/2022, the facility did not ensure that each resident is treated with respect and dignity and cared for in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life. This was identified for one (Resident #489) of two residents reviewed for dignity. Specifically, on 11/9/2021 Resident #489 refused a scheduled shower. Resident #489's right to refuse the shower was not honored; and the staff administered the shower even though the resident refused to be showered. The finding is: The facility's policy for Resident Rights dated 11/2016 documented the resident has a right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility. The policy documented the facility must ensure that the resident can exercise his/her rights without interference, coercion, discrimination, or reprisal from the facility. The policy also documented the resident has the right to refuse and/or discontinue medications and treatments and have the right to be treated with dignity and respect. Resident #489 was admitted with [DIAGNOSES REDACTED]. A Minimum Data Set (MDS) assessment dated [DATE] documented the resident's Brief Interview for Mental Status (BIMS) score was 12 which indicated moderate cognitive impairment. The resident required extensive assistance of one staff for bathing and did not reject care. A Comprehensive Care Plan (CCP) dated 12/13/2020 documented the resident had Activities of Daily Living (ADL) selfcare performance deficit related to a Stroke and Dementia. Interventions included bathing/showering as per the Certified Nursing Assistant (CNA) task. The CCP did not include shower days and the nursing shift that the resident was to be showered. The Certified Nursing Assistant (CNA) accountability record dated 11/2021 documented the resident required extensive assist of one staff member for bathing and receives showers on the 7:00-3:00 shift. An Active Incident report dated 11/9/2021 documented that on 11/9/2021 at approximately 10:30 AM Certified Nursing Assistant (CNA) #6 and CNA #7(student) informed Resident #489 that a shower would be provided. CNA #6 told the resident that they (Resident #489) refused the previous showers and today they (Resident #489) really needed to take a shower. The resident started to yell and then screamed rape rape while they (Resident #489) were fully dressed and in the hallway. When the resident was taken to a shower room, CNA#6 began undressing the resident and identified that there was no hot water. CNA #6 then wrapped Resident #489 in a sheet and with CNA #7 (student) transported the resident to another shower room. While being transported to another shower room Resident #489 again began yelling and screaming rape; however, stopped yelling when the shower began with warm water. The untitled Incident report summary dated 11/12/2021, written by Assistant Director of Nursing Services (ADNS), documented Resident #489 was interviewed by the ADNS and stated, I did not want a shower, it was rough. when questioned what that meant, Resident #489 repeated I did not want a shower. The resident stated no one raped them. CNA #6, who was assigned to Resident #489 on 11/9/2021, was interviewed on 8/18/2022 at 2:42 PM. CNA #6 stated Resident #489 was scheduled for a shower on 11/9/2021. When CNA #6 took the resident to the shower room with another CNA (CNA #7), the water in the shower room was not hot and CNA #6 took Resident #489 to a different shower room. During transport to the other shower room Resident #489 began yelling rape, leave me alone I don't want a shower, rape rape. CNA #6 stated when the resident stated they (Resident #489) did not want a shower, they (CNA #6) were supposed to stop and not give the shower; however, CNA #6 continued to provide the shower to the resident because a student was with them (CNA #6). CNA #6 stated they had to teach the student CNA #7 what to do. CNA #6 stated Resident #489 refused the previous three showers, and they (CNA #6) did not want to get blamed for not providing a shower to the resident. CNA #7 (student) was interviewed on 8/18/2022 at 3:20 PM and stated they were assigned to shadow CNA #6 and was assisting with performing care. CNA #7 (student) stated when they (CNA #6 and CNA #7/student) got to Resident #489 CNA #6 explained to the resident it was their (Resident #489's) shower day and that they (Resident #489) were getting a shower. CNA #7 (student) stated that the resident adamantly refused to be showered. CNA #7 (student) stated that CNA #6 explained to the resident that they had refused several showers prior and that they (Resident #489) had to take the shower. CNA #7 (student) stated that the resident began cursing at CNA #6 and stated they (Resident #489) did not want a shower. CNA #7 (student) stated CNA #6 explained to them (CNA #7) that the resident had to take the shower because they (Resident #489) had not taken a shower in days. The Licensed Practical Nurse (LPN) #2, who was the LPN for Resident #489 on the 7:00 AM - 3:00 PM shift on 11/9/2021, was interviewed on 8/19/2022 at 4:15 PM. LPN #2 stated that Resident #489 has refused showers on multiple occasions and the CNAs know not to force the resident to take a shower. LPN #2 stated that CNA #6 did not report to them (LPN #2) that Resident #489 refused their shower on 11/9/2021. LPN #2 further stated that they did not hear the resident screaming and yelling during transport to the shower room. The Chief Nursing Officer was interviewed on 8/22/2022 at 2:06 PM and stated they were not directly involved with the investigation of this incident; however, if a resident is refusing to be showered and is visibly upset the expectation is that the CNA should stop and report to the nurse that the resident refused to be showered. ADNS #1 was interviewed on 8/22/2022 at 2:40 PM. ADNS #1 stated that due to allegation of rape, police were involved. Resident #489 reported to the Police Officer that they (Resident #489) were not raped and that they (Resident #489) just did not want to take a shower. ADNS #1 stated if the resident did not want to take the shower that the staff should have re-approached the resident. Additionally, ADNS #1 stated that the expectation is that CNA #6 should not have continued to give the resident a shower when the resident refused and should have stopped and re-approached the resident. 415.3(c)(1)(i) | Plan of Correction: ApprovedSeptember 8, 2022 I Resident # 489 no longer resides in the facility The ADNS provided an educational counseling to CNA #6 on 9/7/22 for failing to ensure resident #489 was treated with respect and dignity and failing to ensure the residentÆs right to make choices about receiving a shower were respected. The counseling also included the failure to notify the nurse when the resident refused her shower. CNA # 7 (student) is no longer at the facility. II The Chief Nursing Officer will compile a list of all residents residing on the memory care unit. The list will be utilized by the Assistant Director of Recreation/Nursing Care Coordinator and other memory care unit team members to identify other residents that may refuse showers. Any resident identified that refuses showers/bathing will be reviewed by the team for appropriate Comprehensive Person Care Plan interventions to ensure the are treated with respect and dignity and their choices are honored The Nursing Care Coordinator/Nurse Manager will review the Comprehensive Person Care Plan and CNA task list for all residents on the memory care unit to ensure there is documentation noting shower days and shift the resident is to be showered. Any resident identified that did not have these specific directives identified will have a corrective action initiated. III The Chief Nursing Officer reviewed the facility policy for Resident Rights. The policy was revised to include a directive for notifying the nurse on the unit when care is refused. All nursing staff will be in-serviced on the facility policy on Resident Rights by the Chief Guest Relation Officer/designee. The in-service will have an emphasis on treating a resident with dignity and respect including respecting and honoring their refusal of care, planning care accordingly, and reporting refusals of care. A copy of the lesson plan and attendance sheet will be maintained for validation of the in-service. IV The Chief Quality Officer developed an audit tool to review grievances/accident reports to identify any incidence of a resident right(s) not being honored. Audits will be done by the Chief Quality Officer on all grievances/accident reports monthly x 3 months, quarterly x 3 months and then randomly thereafter. Any quality issues will have immediate corrective actions by the auditor and will be referred to the Chief Nursing Officer and Administrator for follow up review. All audit findings and any identified trends will be presented and discussed at the QAPI committee meetings for evaluation and follow up to ensure ongoing compliance. V. The Chief Quality Officer will be responsible for the correction of this deficiency by (MONTH) 17, 2022. |
Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: August 22, 2022
Corrected date: October 17, 2022
Citation Details **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interviews conducted during the Recertification survey, initiated on 8/15/2022 and completed on 8/22/2022, the facility did not ensure residents who need respiratory care, including [MEDICAL CONDITION] care, are provided such care consistent with professional standards of practice and the Comprehensive Person-Centered Care Plan. This was evident for one (Resident #88) of five residents reviewed for respiratory care. Specifically, Resident #88 had a physician's orders [REDACTED]. During an observation of the [MEDICAL CONDITION] care on 8/17/2022, Resident #88 was observed without a disposable inner cannula in place. The finding is: The facility Policy and Procedure dated 8/1996, and last updated on 8/17/2022 for [MEDICAL CONDITION] care documented: Purpose for the care of the inner cannula is to maintain resident's airway and to keep the area around the [MEDICAL CONDITION] clean. The procedure for the inner cannula care includes to replace the inner cannula daily by the day shift. The inner cannula should be assessed every shift. Resident # 88 has [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) assessment dated [DATE] documented that the resident receives [MEDICAL CONDITION] care and is on a respiratory ventilator. The physician orders [REDACTED].# 8 disposable inner cannula one time a day for hygiene. During a [MEDICAL CONDITION] care observation on 8/17/2022 at 2:43 PM, Respiratory Therapist (RT) # 3 provided the treatment to Resident # 88. Resident # 88 was observed without a disposable inner cannula. RT #3 inserted a new [MEDICATION NAME] # 8 disposable inner cannula. The RT #3 could not explain why the resident did not have a disposable inner cannula in place at the time of the treatment. RT #3 further stated the resident should always have an inner cannula in place. The current Comprehensive Care Plan (CCP) dated 6/7/2022 documented Resident #88 had a [MEDICAL CONDITION] related to Impaired breathing mechanics. Interventions included to provide [MEDICAL CONDITION] care daily and as needed (PRN). Monitor [MEDICAL CONDITION] site for any abnormalities. The Treatment Administration Record documented that RT # 2 provided [MEDICAL CONDITION] care including changing the disposable inner cannula on 8/17/2022 during the day shift. RT #1 provided [MEDICAL CONDITION] care and changed the disposable inner cannula on 8/16/2022. RT # 2 was interviewed on 8/17/2022 at 3:15 PM and stated that they (RT #2) did not change the disposable inner cannula on 8/17/2022 earlier in the day and did not know why they (RT #2) signed the TAR indicating that they (RT #2) changed the resident's disposable inner cannula. RT #2 further stated they (RT #2) only cleaned around the [MEDICAL CONDITION]. RT # 1 was interviewed on 8/22/2022 at 1 PM and stated that they (RT #1) performed [MEDICAL CONDITION] care on (MONTH) 16, 2022 and stated they (RT #1) inserted the new disposable inner cannula after removing the old disposable inner cannula. RT #1 stated they (RT #1) would never leave a resident without a disposable inner cannula. The Registered Nurse (RN) Educator was interviewed on 8/17/2022 at 3:30 PM and stated disposable inner cannula should be in place for hygienic purposes. If the disposable inner cannula is not present, it can compromise the [MEDICAL CONDITION]. The disposable inner cannula can be pulled out when a mucus plug develops or when there are thick secretions. The Director of Respiratory Therapy was interviewed on 8/17/2022 at 4:45 PM and stated Resident # 88 has a [MEDICAL CONDITION] that should always have an inner cannula. The [MEDICAL CONDITION] is replaced once every 56 days as per the facility policy. If the inner cannula is not in place, the [MEDICAL CONDITION] may have to be replaced more frequently than 56 days. The inner cannula may have a buildup of secretions and/or mucus plugs. The inner cannula should be changed on a daily basis or as needed and should always be in place. 415.12(k)(6) | Plan of Correction: ApprovedSeptember 8, 2022 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** I Resident #88 currently resides in the facility and is receiving [MEDICAL CONDITION] care consistent with professional standards of practice, MD orders, and Comprehensive care plan. The resident was seen and evaluated by the medical staff on 8/22/22, 8/23/22, 8/24/22, 8/25/22, and 8/26/22 and is currently not noted with any respiratory issues. Respiratory Therapist # 2 received an educational counseling on 8/22/22 by the Director of Respiratory Therapy for failing to ensure the disposable inner cannula was in place for resident #88 on 8/17/22. Respiratory Therapist #2 was suspended on 8/29/22 for documenting services that he did not personally provide on 8/17/22 during the day shift for resident #88. II The Director of Respiratory Therapy developed a list of all facility residents with orders for disposable inner cannulas on 8/17/22. Using this list, the Director of Respiratory Therapy made rounds on all residents to ensure all residents with orders for disposable inner cannulas had them in place as per MD order. There were no additional quality issues identified. The Director of Respiratory Therapy developed a list of all facility residents with orders for disposable inner cannulas on 9/1/22. Using this list, the Director of Respiratory Therapy made rounds on all residents to ensure the disposable inner cannula was in place as per MD orders. There were no quality issues were identified. III The Director of Respiratory Therapy and the Medical Director reviewed the facility policy on [MEDICAL CONDITION] Care. The policy was revised to include a directive to check the inner cannula for placement and patency every shift. These checks will now be documented by the Respiratory Therapist on the respiratory TAR. All Respiratory Therapists will be in-serviced on the revised policy by the Director of Respiratory Therapy. A copy of the lesson plan and attendance will be maintained for validation. The Director of Respiratory reviewed the facility policy on documentation of [MEDICAL CONDITION] care. The policy was found to be compliant. All respiratory therapists will be re-in serviced on the facility policy, with an emphasis on accurate and timely documentation of respiratory care that he/she has personally provided. A copy of the lesson plan and attendance will be maintained for validation. IV The Chief Quality Officer will develop an audit tool to monitor compliance with the facility policy on documenting placement and patency of disposable inner cannula including accurate/timely documentation of [MEDICAL CONDITION] care. Audits will be done by the Director of Respiratory Therapy on all residents with disposable inner cannulas weekly x 3 weeks, monthly x 3 months, then quarterly. Any quality issues identified will have immediate corrective action by the auditor and referred to Administrator and Chief Quality Officer for follow up review. All audit findings and any identified trends will be presented and discussed at the QAPI committee meetings for evaluation and follow up to ensure ongoing compliance thereafter. V. The Director of Respiratory Therapy will be responsible for the correction of this deficiency by (MONTH) 17, 2022. |
Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: August 22, 2022
Corrected date: October 17, 2022
Citation Details **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interviews during the Recertification Survey and Abbreviated Survey (NY 250) initiated on 8/15/2022 and completed on 8/22/2022, the facility did not ensure that each resident has a right to make choices about aspects of his or her life in the facility that are significant to the resident. This was identified for one (Resident #489) of one resident reviewed for choices. Specifically, on 11/9/2021 Resident #489 refused a scheduled shower and the staff administered the shower even though the resident refused to be showered. The finding is: The facility Bathing/Personal Care Policy dated 10/2008 documented if the resident refuses the bath/shower, the nurse is to be notified. This is to be noted by the nurse in a quick note in the electronic medical record (EMR). Resident #489 was admitted with [DIAGNOSES REDACTED]. A Minimum Data Set ((MDS) dated [DATE] documented the resident's Brief Interview for Mental Status (BIMS) score as 12 which indicated moderate cognitive impairment. The MDS indicated Resident # 489 required extensive assistance of one staff member for bathing and did not reject care. A Comprehensive Care Plan (CCP) dated 12/13/2020 documented the resident had Activities of Daily Living (ADL) selfcare performance deficit related to a Stroke and Dementia. Interventions included bathing/showering as per the Certified Nursing Assistant (CNA) task. The CCP did not include shower days and what nursing shift the resident was to be showered. The CNA accountability record dated 11/2021 documented the resident required extensive assist of one staff member for bathing and receives showers on the 7:00-3:00 shift. An Active Incident report dated 11/9/2021 documented that on 11/9/2021 at approximately 10:30 AM Certified Nursing Assistant (CNA) #6 and CNA #7(student) informed Resident #489 that a shower would be provided. CNA #6 told the resident that they (Resident #489) refused the previous showers and today they (Resident #489) really needed to take a shower. The resident started to yell and then screamed rape rape while they (Resident #489) were fully dressed and in the hallway. When the resident was taken to a shower room, CNA #6 began undressing the resident and identified that there was no hot water. CNA #6 then wrapped Resident #489 in a sheet and with CNA #7 (student) transported the resident to another shower room. While being transported to another shower room Resident #489 again began yelling and screaming rape; however, stopped yelling when the shower began with warm water. The untitled Incident report summary dated 11/12/2021, written by Assistant Director of Nursing Services (ADNS), documented Resident #489 was interviewed by the ADNS and stated, I did not want a shower, it was rough. when questioned what that meant, Resident #489 repeated I did not want a shower. The resident stated no one raped them. CNA #6, who was assigned to Resident #489 on 11/9/2021, was interviewed on 8/18/2022 at 2:42 PM. CNA #6 stated Resident #489 was scheduled for a shower on 11/9/2021. When CNA #6 took the resident to the shower room with another CNA (CNA #7), the water in the shower room was not hot and CNA #6 took Resident #489 to a different shower room. During transport to the other shower room Resident #489 began yelling rape, leave me alone I don't want a shower, rape rape. CNA #6 stated when the resident stated they (Resident #489) did not want a shower, they (CNA #6) were supposed to stop and not give the shower; however, CNA #6 continued to provide the shower to the resident because a student was with them (CNA #6). CNA #6 stated they had to teach the student (CNA #7) what to do. CNA #6 stated Resident #489 refused the previous three showers, and they (CNA #6) did not want to get blamed for not providing a shower to the resident. CNA #7 (student) was interviewed on 8/18/2022 at 3:20 PM and stated they were assigned to shadow CNA #6 and was assisting with performing care. CNA #7 (student) stated when they (CNA #6 and CNA #7/student) got to Resident #489 CNA #6 explained to the resident it was their (Resident #489's) shower day and that they (Resident #489) were getting a shower. CNA #7 (student) stated that the resident adamantly refused to be showered. CNA #7 (student) stated that CNA #6 explained to the resident that they had refused several showers prior and that they (Resident #489) had to take the shower. CNA #7 (student) stated that the resident began cursing at CNA #6 and stated they (Resident #489) did not want a shower. CNA #7 (student) stated CNA #6 explained to them (CNA #7) that the resident had to take the shower because they (Resident #489) had not taken a shower in days. The Licensed Practical Nurse (LPN) #2, who was the LPN for Resident #489 on the 7:00 AM - 3:00 PM shift on 11/9/2021, was interviewed on 8/19/2022 at 4:15 PM. LPN #2 stated that Resident #489 has refused showers on multiple occasions and the CNAs know not to force the resident to take a shower. LPN #2 stated that CNA #6 did not report to them (LPN #2) that Resident #489 refused their shower on 11/9/2021. LPN #2 further stated that they did not hear the resident screaming and yelling during transport to the shower room. The Chief Nursing Officer was interviewed on 8/22/2022 at 2:06 PM and stated they were not directly involved with the investigation of this incident; however, if a resident is refusing to be showered and is visibly upset the expectation is that the CNA should stop and report to the nurse that the resident refused to be showered. ADNS #1 was interviewed on 8/22/2022 at 2:40 PM. ADNS #1 stated that due to allegation of rape, police were involved. Resident #489 reported to the Police Officer that they (Resident #489) were not raped and that they (Resident #489) just did not want to take a shower. ADNS #1 stated if the resident did not want to take the shower that the staff should have re-approached the resident. Additionally, ADNS #1 stated that the expectation is that CNA #6 should not have continued to give the resident a shower when the resident refused and should have stopped and re-approached the resident. 415.5(b)(1-3) | Plan of Correction: ApprovedSeptember 8, 2022 I Resident # 489 no longer resides in the facility The ADNS provided an educational counseling to CNA #6 on 9/7/22 for failing to ensure resident #489 was treated with respect and dignity and failing to ensure the residentÆs right to make choices about receiving a shower were respected. The counseling also included the failure to notify the nurse when the resident refused her shower. CNA # 7 (student) is no longer is at the facility. II The Chief Nursing Officer will compile a list of all residents residing on the memory care unit. The list will be utilized by the Assistant Director of Recreation/Nursing Care Coordinator and other memory care unit team members to identify other residents that may refuse showers. Any resident identified that refuses showers/bathing will be reviewed by the team for appropriate Comprehensive Person Care Plan interventions to ensure their choices are honored. The Nursing Care Coordinator/Nurse Manager reviewed the Comprehensive Person Care Plan and CNA task list for all residents on the memory care unit to ensure there is documentation noting shower days and shift the resident is to be showered. Any resident identified that did not have these specific directives identified will have a corrective action initiated. III The Chief Nursing Officer reviewed the facility policy on Bathing/Personal Care. The policy was revised to include directive that if the resident refuses bath/shower the nurse will be notified and resident will be discussed at team meeting for appropriate care plan interventions. All Nursing staff will be in-serviced on the policy by the Chief Guest Relations Officer/Designee. The in-service will have an emphasis on residents to be able to make choices about aspects of his or her life that are significant to them specifically, in relation to bathing/personal care, refusal of care, and providing care accordingly. A copy of the lesson plan and attendance sheet will be maintained for validation of the in-service. IV The Chief Quality Officer will develop an audit tool to review grievances/accident reports to identify any incidence of a residentÆs choices not being honored. Audits will be done by the Chief Quality Officer on all grievances/accident reports monthly x 3 months, quarterly x 3 months and then randomly thereafter. Any quality issues will have immediate corrective actions by the auditor and will be referred to the Chief Nursing Officer and Administrator for follow up review. All audit findings and any identified trends will be presented and discussed at the QAPI committee meetings for evaluation and follow up to ensure ongoing compliance thereafter V. The Chief Quality Officer will be responsible for the correction of this deficiency by (MONTH) 17, 2022. |
Scope: Widespread
Severity: Potential to cause more than minimal harm
Citation date: October 26, 2022
Corrected date: November 3, 2022
Citation Details 2012 NFPA 101: 19.1.6 Minimum Construction Requirements. 19.1.6.1 Health care occupancies shall be limited to the building construction types specified in Table 19.1.6.1, unless otherwise permitted by 19.1.6.2 through 19.1.6.7. (See 8.2.1.) Life Safety Code Section 19.1.6 and Table 19.1.6.1 limit the height of buildings that are built of unprotected non-combustible construction (i.e., NFPA 220 Type II (000) building construction) to only two stories with a complete automatic sprinkler system. This requirement is not met as evidenced by: Based on observation, staff interview, and record review during the Life Safety Code recertification survey, the existing health care facility was observed to be a Type II (000) construction for a building that is greater than two stories in height. A rated ceiling assembly to address the construction type limitations could not be determined for the building. This was noted for the Schacne Pavilion. Aditionally, the faciity identified improperly sealed floor slab penetrations by the HVAC and plumbing systems. The findings are: During the Life Safety Code inspections of the Schacne Pavilion on 08/15/22, and on 08/16/22, between 8:30am and 3:00pm, multiple observations made during the survey of the four-storey building revealed that a fire-resistant rated inlay ceiling assembly had not been maintained or could not be determined. The observations above the inlay drop ceiling revealed light fixtures in ceiling assemblies on floors 1 through 4 that were not properly enclosed in fire resistance rated construction. Multiple observations further revealed that the steel structural members (i.e., joists and steel support beams) in the building were not provided with fire proofing on floors 1-4. The lack of adequate fire proofing on steel structural members or not having a fire resistance rated ceiling assembly would mean that this building would be considered a Type II (000) Unprotected, Non-combustible structure. The Life Safety Code prohibits existing health care occupancies from utilizing buildings of Type II (000) construction that are more than two stories in height. Although the facility provided specifications of the materials used in the ceiling assembly, the listed assembly system or certification of a rated ceiling assembly was not provided in order to determine if the ceiling assembly meets the requirements to address the construction type limitations of the building. Additionally, the facility had previously identified a total of approximately 946 separate improperly sealed plumbing and HVAC penetrations in floor and ceiling slabs. The plumbing penetrations come through the decking into a sheetrock wall above, and the HVAC piping come through the metal decking into the equipment above. During the Life Safety Code exit conference on 08/19/22 at 2:00pm, the Administrator and Director of Engineering were both made aware of the issues. 10 NYCRR 415.29 10 NYCRR 711.2(a)(1) 2012 NFPA 101: 19.1.6.1. 8.2.1, 8.2.1.2 2012 NFPA 220: 4.1Based on record review during the Life Safety Code Post Survey Revisit on 10/25/2022 the facility did not provide substantial information to demonstrate that the Plan Of Corrections were implemented for the identified improperly sealed floor slab penetrations by the HVAC and plumbing systems. The following was cited during the 08/22/2022 recertification survey: During the Life Safety Code inspections on 08/15/22, and on 08/16/22, between 8:30am and 3:00pm, and record review, it was noted that the facility had previously identified a total of approximately 946 separate improperly sealed plumbing and HVAC penetrations in floor and ceiling slabs. The plumbing penetrations come through the decking into a sheetrock wall above, and the HVAC piping come through the metal decking into the equipment above. During the Life Safety Code exit conference on 08/19/22 at 2:00pm, the Administrator and Director of Engineering were both made aware of the issues. 10 NYCRR 415.29 10 NYCRR 711.2(a)(1) 2012 NFPA 101: 19.1.6.1. 8.2.1, 8.2.1.2 2012 NFPA 220: 4.1 | Plan of Correction: ApprovedNovember 8, 2022 K 161 1. What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice There were no residents cited in this K tag. On 9/14/22 the facility received documentation from Tobin & ParnÆs Design Architects that the original design meets or exceeds construction type II (222) per NFPA [PHONE NUMBER], which per NFPA [PHONE NUMBER]- table 19.1.6.1 is permitted for sprinkler building over 4 +stories. This is represented in the original design drawings which indicate that the Schachne building is protected by a 2 hr. rated ceiling / floor assembly, which consists of a fire rated ceiling (in lieu of steel fireproofing). The facility maintains the documentation from the Architect who evaluated the ceiling design and determined that the Schachne building is in compliance with NFPA 101 . In regard to the facility had previously identified a total of approximately 946 separate improperly sealed plumbing and HVAC penetrations in floor and ceiling slabs. The plumbing penetrations come through the decking into a sheetrock wall above, and the HVAC piping come through the metal decking into the equipment above. The facility is consulting with professional teams of engineers and architects to complete an FSES. The facility will submit a completed FSES to NYS DOH for approval by 10/17/22. 2. How you will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken All residents could be affected by this deficiency. The Engineering department has completed a full building audit and all lighting fixtures located in the Schachne building have been inspected to ensure they are enclosed in a fire rated tent construction. Any quality issue which was identified have been addressed and are in compliance at this time. All engineering staff have been in serviced in the proper method to enclose lighting fixtures 3. What measures will be put in place or what systemic changes you will make to ensure that the deficient practice does not recur Chief Engineering Officer or designee will monitor all materials used for repairs of the existing ceiling. All materials will meet the specifications of original design or exceed the requirements of the required NFPA [PHONE NUMBER] All Engineering Staff have been in serviced on this policy and the K161 requirement by the Chief Engineering Officer/Designee. The Chief Engineering Officer/Designee has completed an in-service with all Engineering Staff on the proper lighting fixture tenting requirement if a light fixture needs to be moved for any reason. 4. How the corrective action(s) will be monitored to ensure the deficient practice will not recur, i.e., what quality assurance program will be put into practice. The Engineering staff will conduct an audit on all units annually due to the number of lighting fixtures and the extent of the inspection. 1 floor per quarter will be conducted to reach complete compliance yearly. All fixtures will be inspected to ensure they are enclosed in fire resistant rated construction. Any quality issue identified will have immediate corrective action taken. The results of audits will be presented to the QAPI committee for evaluation and review yearly. 5. The date for correction and the title of the person responsible for correction of each deficiency Chief Engineering Officer by 10/17/22 |
Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: August 22, 2022
Corrected date: October 17, 2022
Citation Details 2012 NFPA 101: 19.2.2.2.5.1* Door-locking arrangements shall be permitted where the clinical needs of patients require specialized security measures or where patients pose a security threat, provided that staff can readily unlock doors at all times in accordance with 19.2.2.2.6. 19.2.2.2.6 Doors that are located in the means of egress and are permitted to be locked under other provisions of 19.2.2.2.5 shall comply with all of the following: (1) Provisions shall be made for the rapid removal of occupants by means of one of the following: (a) Remote control of locks (b) Keying of all locks to keys carried by staff at all times (c) Other such reliable means available to the staff at all times (2) Only one locking device shall be permitted on each door. (3) More than one lock shall be permitted on each door, subject to approval of the authority having jurisdiction. 7.1.9 Impediments to Egress. Any device or alarm installed to restrict the improper use of a means of egress shall be designed and installed so that it cannot, even in case of failure, impede or prevent emergency use of such means of egress, unless otherwise provided in 7.2.1.6 and Chapters 18, 19, 22, and 23. 7.2.1.6.1 Delayed-Egress Locking Systems. 7.2.1.6.1.1 Approved, listed, delayed-egress locking systems shall be permitted to be installed on door assemblies serving low and ordinary hazard contents in buildings protected throughout by an approved, supervised automatic fire detection system in accordance with Section 9.6 or an approved, supervised automatic sprinkler system in accordance with Section 9.7, and where permitted in Chapters 11 through 43, provided that all of the following criteria are met: (1) The door leaves shall unlock in the direction of egress upon actuation of one of the following: (a) Approved, supervised automatic sprinkler system in accordance with Section 9.7 (b) Not more than one heat detector of an approved, supervised automatic fire detection system in accordance with Section 9.6 (c) Not more than two smoke detectors of an approved, supervised automatic fire detection system in accordance with Section 9.6 (2) The door leaves shall unlock in the direction of egress upon loss of power controlling the lock or locking mechanism. (3)*An irreversible process shall release the lock in the direction of egress within 15 seconds, or 30 seconds where approved by the authority having jurisdiction, upon application of a force to the release device required in 7.2.1.5.10 under all of the following conditions: (a) The force shall not be required to exceed 15 lbf (67 N). (b) The force shall not be required to be continuously applied for more than 3 seconds. (c) The initiation of the release process shall activate an audible signal in the vicinity of the door opening. (d) Once the lock has been released by the application of force to the releasing device, relocking shall be by manual means only. (4)*A readily visible, durable sign in letters not less than 1 in. (25 mm) high and not less than 1/8 in. (3.2 mm) in stroke width on a contrasting background that reads as follows shall be located on the door leaf adjacent to the release device in the direction of egress: PUSH UNTILALARM SOUNDS DOOR CAN BE OPENED IN 15 SECONDS (5) The egress side of doors equipped with delayed-egress locks shall be provided with emergency lighting in accordance with Section 7.9. Based on observation and staff interview during the recertification survey, the facility did not ensure that the required posted instructions for delayed egress locks on egress doors were maintained legible in the Schacne Pavilion. The findings are: During the Life Safety Code survey on 08/15/2022 survey between 9:30am and 3:45pm, it was noted that the delayed egress instruction signages were painted over and not legible. Examples included: Stair C on the 2 South Unit, and Stair B on the 1 South Unit. In an interview on 08/15/2022 at 3:00pm, the Director of Engineering stated replacement delayed egress signs would be posted on the doors. 10 NYCRR 415.29 10 NYCRR 711.2(a)(1) 2012 NFPA 101 | Plan of Correction: ApprovedSeptember 16, 2022 K222 1. What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice There were no residents cited in this K tag. The door on Stair C on the 2 South Unit and Stair B on the 1 South Unit were repaired and currently have legible posted instructions for the delayed egress locks. 2. How you will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken All residents could be affected by this deficiency. The Chief Engineering Officer made rounds throughout the facility to identify if there were any other egress doors that did not have the required posted instructions for delayed egress locks legibly posted. There were no quality issues identified. 3. What measures will be put in place or what systemic changes you will make to ensure that the deficient practice does not recur Gurwin Engineering staff as part of the PM program will conduct Quarterly Door inspections in accordance with QIS Monitoring Tool to identify any problem areas. Required yearly inspections will be performed as required and documented on log All Engineering staff will be in serviced on door maintenance, K222 requirement and repair log completion by the Chief Engineering Officer/Designee. 4. How the corrective action(s) will be monitored to ensure the deficient practice will not recur, i.e., what quality assurance program will be put into practice Chief Engineering Officer or designee will review all door inspections for compliance that are documented on log Gurwin Chief Engineering Officer will monitor the logs each quarter and report the findings at the scheduled QAPI meeting After 12 months of compliance, door inspection will move to a semiannual reporting with an additional 12 months After 24 months with 100% compliance door monitoring will be reported at the year-end meeting of QAPI 5. The date for correction and the title of the person responsible for correction of each deficiency Chief Engineering Officer by 10/17/22 |
Scope: Widespread
Severity: Potential to cause more than minimal harm
Citation date: October 26, 2022
Corrected date: November 4, 2022
Citation Details 2012 NFPA 101: 9.1.3.1 Emergency generators and standby power systems shall be installed, tested , and maintained in accordance with NFPA 110, Standard for Emergency and Standby Power Systems. 2010 NFPA 110: 5.6.5.6* All installations shall have a remote manual stop station of a type to prevent inadvertent or unintentional operation located outside the room housing the prime mover, where so installed, or elsewhere on the premises where the prime mover is located outside the building. 5.6.5.6.1 The remote manual stop station shall be labeled. 2010 NFPA 110: Standard for Emergency and Standby Power Systems 8.4.8 The routine maintenance and operational testing program shall be overseen by a properly instructed individual. 8.4.9* Level 1 EPSS shall be tested at least once within every 36 months. 8.4.9.1 Level 1 EPSS shall be tested continuously for the duration of its assigned class (see Section 4.2). 8.4.9.2 Where the assigned class is greater than 4 hours, it shall be permitted to terminate the test after 4 continuous hours. Based on observation, and staff interview during the recertification survey, the facility did not ensure that two of two emergency generator sets were provided with remote manual stop stations (emergency shut offs) outside the generator rooms for generator #1 and #2. Additionally, there was no documented evidence that 1 of 2 generators was exercised once every 36 months for 4 continuous hours as required. During the Life Safety Code survey on 08/18/2022 at 11:00am, it was noted that Generator #2 that is located within a room in the Weinberg Pavilion was not equipped a remote manual stop station located outside of the room. During the Life Safety Code survey on 08/18/2022 at 11:35am, it was noted that Generator #1 was located within a room on the roof of the B- building and was not equipped a remote manual stop station located outside of the room. In an interview on 08/18/2022 at 11:35am, the Director of Engineering stated that the facility received quotes for the stop buttons and that they would be installed. During a documentation review the facility's emergency generator maintenance records on 08/19/2022 at 9:45am, there was no documentation provided for a continuous four-hour exercise for generator set # 1 within the last thirty-six months. 2012NFPA 101 2010NFPA 110 10 NYCRR 415.29 10NYCRR 711.2(a)(1)2012 NFPA 101: 9.1.3.1 Emergency generators and standby power systems shall be installed, tested , and maintained in accordance with NFPA 110, Standard for Emergency and Standby Power Systems. 2010 NFPA 110: 5.6.5.6* All installations shall have a remote manual stop station of a type to prevent inadvertent or unintentional operation located outside the room housing the prime mover, where so installed, or elsewhere on the premises where the prime mover is located outside the building. 5.6.5.6.1 The remote manual stop station shall be labeled. Based on record review during the Life Safety Code Post Survey Revisit on 10/25/2022 the facility did not provide substantial information to demonstrate that the Plan Of Corrections were implemented for one of two emergency generator sets in that there was no evicence for the installation of a remote stop station for generator #1. The finding is: The facility was cited for the following during the 08/22/2022 recertification survey. During the Life Safety Code survey on 08/18/2022 at 11:35am, it was noted that Generator #1 was located within a room on the roof of the B- building and was not equipped a remote manual stop station located outside of the room. 2012NFPA 101 2010NFPA 110 10 NYCRR 415.29 10NYCRR 711.2(a)(1) | Plan of Correction: ApprovedNovember 4, 2022 K918 1. What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice There were no residents cited in this K tag. On 9/14/2022 both generators # 1 and # 2 were exercised in accordance with NFPA 110(10), Chapter 8 Routing Maintenance and Operational Testing. Each unit was run under load gen # 1-4.5 hours gen #2-4 hours. All records are kept in the facilities office for review. There were no issues identified. On 8/29/22 generator #2 was equipped with a remote manual stop station located outside of the room The facility has contracted with Gen Serv to install a remote manual stop station for generator #1. Parts are on order and unit will be fitted with the new switch by 10/17/2022 2. How you will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken All residents could be affected by this deficiency. 3. What measures will be put in place or what systemic changes you will make to ensure that the deficient practice does not recur The Chief Engineering Officer reviewed the requirement on generator testing and K 918. Generator 4 hr testing will now be documented on the (MONTH) and (MONTH) PM records for generator set #1 and generator set #2. To comply with the 36-month 4hr testing requirements. The facility engineering staff will continue to test generator #1 and #2 in accordance with NFPA 110(10), Chapter 8 Routine Maintenance and Operational Testing monthly as required and a 4hr test will be conducted during the months of (MONTH) and (MONTH) to ensure compliance is met. All engineering staff will be in serviced on the generator testing regulation and documentation on PM records by the Chief Engineering Officer/Designee. The Chief Engineering Officer/Designee will in-service all engineering staff on the requirement for generators to have a remote manual stop station outside the room. 4. How the corrective action(s) will be monitored to ensure the deficient practice will not recur, i.e., what quality assurance program will be put into practice The Chief Engineer will Report during QAPI meeting in (MONTH) and (MONTH) that all generator testing has been satisfied and to ensure that at least one 4 hr. test has been completed per year. 5. The date for correction and the title of the person responsible for correction of each Deficiency Chief Engineering Officer by 10/17/22 |
Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: August 22, 2022
Corrected date: October 17, 2022
Citation Details **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2012 NFPA 101: 19.3.7.8 Doors in smoke barriers shall comply with 8.5.4 and all of the following: (1) The doors shall be self-closing or automatic-closing in accordance with 19.2.2.2.7. (2) Latching hardware shall not be required (3) The doors shall not be required to swing in the direction of egress travel. 2012 NFPA 101: 8.5.4.4 Doors in smoke barriers shall be self-closing or automatic-closing in accordance with 7.2.1.8 and shall comply with the provisions of 7.2.1. 2012 NFPA 101: 7.2.1.15.2 Fire-rated door assemblies shall be inspected and tested in accordance with NFPA 80, Standard for Fire Doors and Other Opening Protectives. Smoke door assemblies shall be inspected and tested in accordance with NFPA 105, Standard for Smoke Door Assemblies and Other Opening Protectives. 2010 NFPA 105: 4.1.1 Fire door assemblies that are intended for use as smoke door assemblies shall also comply with NFPA 80, Standard for Fire Doors and Other Opening Protectives. 2010 NFPA 80: 4.2.1* Listed items shall be identified by a label. This requirement is not met as evidenced by: Based on observation and staff interview during the recertification survey, the facility did not ensure that doors within smoke barriers that are required to be fire-rated doors were provided with legible fire-rated labels. This was noted in the Schacne Pavilion and in the A-Building. The findings are: During the Life Safety Code survey 0n 08/15/2022, 08/16/2022, and on 08/17/2022 between 9:30am and 3:45pm, it was noted that the fire resistance labels on smoke barrier doors were not legible or were painted over in the Schacne Pavilion and in the A-Building. Examples included but are not limited to the following locations: Schacne Pavilion - In the corridor near room [ROOM NUMBER] of the 4th floor - In the corridor near room [ROOM NUMBER] of the 3rd floor - In the corridor near room [ROOM NUMBER] of the 2nd floor - In the corridor near room [ROOM NUMBER] of the 1st floor Weinberg Pavilion - In the corridor near rooms 454, 458 and 470 of the 4th floor. A Building - In the corridor near the Rehabilitation Department. In an interview on 08/17//2022 at 11:55am, the Director of Engineering stated that the facility would look into getting the doors rectified by an outside company. 2012 NFPA 101: 2010 NFPA105: 2010 NFPA 80: 2010 NFPA 105: 4.1.1 10NYCRR 711.2(a)(1) | Plan of Correction: ApprovedSeptember 16, 2022 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** K374 1. What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice There were no residents cited in this K tag. 2. How you will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken All residents could be affected by this deficiency. The Chief Engineering officer has conducted a survey of the complete Gurwin buildings known as Schachne and Weinberg and has identified a combination of 101 doors and frames that will need to be re labeled with UL listed labels Gurwin has consulted with a door labeling company and retained their services to inspect and label 101 doors and frames through the complete facility in accordance with the NFPA 101 and with NFPA 80, 2012 edition and door construction. Examples included but are not limited to the following locations: Schachne Pavilion In the corridor near room [ROOM NUMBER] of the 4th floor In the corridor near room [ROOM NUMBER] of the 3rd floor 3. What measures will be put in place or what systemic changes you will make to ensure that the deficient practice does not recur Gurwin Engineering staff as part of the PM program will conduct Quarterly Door inspections in accordance with QIS Monitoring Tool to identify any problem areas on attached QIS Form. Required yearly inspections will be preformed as required and documented on monthly and yearly log sheet All Engineering staff will be in serviced on door maintenance, K 374 requirement and repair log completion by the Chief Engineering Officer/Designee The Chief Engineering Officer/Designee will review all door inspections for compliance with no end date. This will be part of the facility's maintenance program for door maintenance. 4. How the corrective action(s) will be monitored to ensure the deficient practice will not recur, i.e., what quality assurance program will be put into practice Gurwin Chief Engineering officer will monitor the logs each quarter and report the findings at the scheduled QAPI meeting After 12 months of compliance, the door inspection audits will be reported semiannually. After 24 months with ,100% compliance, door monitoring audits will be reported at the QAPI meeting. 5. The date for correction and the title of the person responsible for correction of each deficiency Chief Engineering Officer by 10/17/22 |